Dominique Baileull •
M AM 1 lEACH
DIVERSITY STATISTICS REPORTING
Name:: ��►�rn� � � k tsa�
Board / Committee: , 87: iIVA �
Appointment Date: c=.3 22- /" 2c--I
Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually
prepare and present a report to the City Commission identifying the City's diversity
statistics. This form allows board and committee applicants and members to voluntarily
self-identify their race, ethnicity, disabled status and gender.
Please check the appropriate box for each category:
Gender: Male VIA Female
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White
LD Asian or Pacific Islander
Native-American/American Indian
j = Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
No
Yes
Do you consider yourself Physically Disabled?
-No
Yes
C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-1.3 FINAL.doc
Updated: Monday,January 26,2015